WHO/HIV/2013.17
© World Health Organization 2013
GRADE tables for additional adherence interventions Author(s): Martina Penazzato and Amitabh Suthar Date: 2013-02-08 Question: Should nutritional support be used for improving adherence to antiretroviral therapy among food-insecure individuals? Settings: Low- and middle-income countries Bibliography: Cantrell RA, Sinkala M, Megazinni K, Lawson-Marriott S, Washington S, Chi BH, Tambatamba-Chapula B, Levy J, Stringer EM, Mulenga L, Stringer JS. A pilot study of food supplementation to improve adherence to antiretroviral therapy among food-insecure adults in Lusaka, Zambia. J Acquir Immune Defic Syndr. 2008 Oct 1;49(2):190-5. Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Nutritional Relative Control support (95% CI) Absolute
Adherence <95% (follow-up 12 months; assessed with: pharmacy refills during the first year of ART) 1 observational studies no serious no serious risk of inconsistency2 1 bias no serious indirectness no serious imprecision none 108/366 (29.5%) 87/166 (52.4%) RR 0.67 (0.56 to 0.83) 173 fewer per 1000 ⊕⊕ΟΟ CRITICAL (from 89 fewer to LOW 231 fewer)
Significant differences between intervention and comparator groups with respect to advanced WHO stage and low CD4 counts. However, final model included gender, age, baseline CD4 count, baseline WHO stage, and baseline hemoglobin. 2 One study identified
1
WHO/HIV/2013.17
© World Health Organization 2013
Author(s): Martina Penazzato and Amitabh Suthar Date: 2013-02-08 Question: Should financial support vs standard of care be used for improving adherence to antiretroviral therapy? Settings: Low- and middle-income countries Bibliography: Muñoz M, Finnegan K, Zeladita J, Caldas A, Sanchez E, Callacna M, Rojas C, Arevalo J, Sebastian JL, Bonilla C, Bayona J, Shin S. Community-based DOT-HAART accompaniment in an urban resource-poor setting. AIDS Behav. 2010 Jun;14(3):721-30. doi: 10.1007/s10461-009-9559-5.
Quality assessment
No of patients
Effect Quality Importance
No of studies
Design
Risk of bias
Inconsistency Indirectness Imprecision
Other considerations
Financial support
Standard of care
Relative (95% CI)
Absolute
Adherence < 95% (follow-up 12 months; assessed with: Self-reported) 1 observational studies serious1 no serious inconsistency2 serious3 no serious imprecision none 12/60 (20%) 23/60 (38.3%) RR 0.52 (0.29 to 0.95) 184 fewer per 1000 ⊕ΟΟΟ (from 19 fewer to VERY 272 fewer) LOW CRITICAL
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Self-reported adherence susceptible to recall and social desirability bias One study identified 3 Financial support for diagnostic testing was combined with community-based directly observed ART
WHO/HIV/2013.17
© World Health Organization 2013
Author(s): Martina Penazzato and Amitabh Suthar Date: 2013-02-08 Question: Should opioid substitution therapy be used for improving adherence to ART among people who inject drugs? Settings: Low- and middle-income countries Bibliography: Lucas GM, Mullen BA, Weidle PJ, Hader S, McCaul ME, Moore RD. Directly administered antiretroviral therapy in methadone clinics is associated with improved HIV treatment outcomes, compared with outcomes among concurrent comparison groups. Clin Infect Dis. 2006 Jun 1;42(11):1628-35. Quality assessment No of patients Effect Quality Importance No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Opioid substitution therapy Control Relative (95% CI) Absolute
Treatment failure (follow-up 12 months; assessed with: Viral load > 400 copies/mL) 1 observational studies serious1 no serious inconsistency2 serious3 serious4 none 38/75 (50.7%) 122/244 (50%) RR 1.01 (0.78 to 1.31) 5 more per 1000 (from 110 fewer to 155 more) ⊕ΟΟΟ VERY LOW CRITICAL
1 Comparison between study arms of people who inject drugs on opiate substitution therapy and people who inject drugs off opiate substitution therapy was not a formal comparison. Crude risk data was used which is susceptible to confounding 2 One study identified 3 This study was conducted in the US. The effect size may be different in low- and middle-income countries 4 Confidence interval for effect estimate indicates benefit and lack of benefit
WHO/HIV/2013.17
© World Health Organization 2013
Author(s): Amitabh Suthar Date: 2013-02-11 Question: Should treatment of depression be used for improving adherence to ART among eligible adults? Settings: Low- and middle-income countries Bibliography: Pyne JM, Fortney JC, Curran GM, Tripathi S, Atkinson JH, Kilbourne AM, Hagedorn HJ, Rimland D, Rodriguez-Barradas MC, Monson T, Bottonari KA, Asch SM, Gifford AL. Effectiveness of collaborative care for depression in human immunodeficiency virus clinics. Arch Intern Med. 2011 Jan 10;171(1):23-31.
Quality assessment
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Effect Quality Importance
No of studies
Design
Risk of bias
Inconsistency Indirectness Imprecision
Other considerations
Treatment of Control depression
Relative (95% CI)
Absolute
Adherence <95% (follow-up 12 months; assessed with: Self-reported) 1 randomised serious1 no serious trials inconsistency2 serious3 serious4 none 24/92 (26.1%) 22/86 (25.6%) OR 0.63 (0.43 to 2.00) 78 fewer per 1000 (from 127 fewer to 152 more) ⊕ΟΟΟ VERY LOW CRITICAL
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Self-reported adherence susceptible to recall and social desirability bias One study identified 3 Study conducted in USA. Effect size may be different in low- and middle-income countries 4 Confidence limit indicated a benefit and a lack of benefit
WHO/HIV/2013.17
© World Health Organization 2013
Author(s): Amitabh Suthar Date: 2013-02-08 Question: Should alarms vs standard of care be used for improving adherence to ART? Settings: Low- and middle-income countries Bibliography: Chung MH, Richardson BA, Tapia K, Benki-Nugent S, Kiarie JN, et al. (2011) A randomized Controlled Trial Comparing the Effects of Counseling and Alarm Device on HAART Adherence and Virologic Outcomes. PLoS Med 8(3): e1000422.
Quality assessment
No of patients
Effect Quality Importance
No of studies
Design
Risk of bias
Inconsistency
Indirectness Imprecision
Other Standard Alarms considerations of care
Relative (95% CI)
Absolute
Treatment failure (follow-up 18 months; assessed with: Viral load > 5,000 cp/mL) 1 randomised no serious no serious trials risk of bias inconsistency1 no serious indirectness serious2 none 44/173 (25.4%) 45/188 (23.9%) HR 0.99 (0.53 to 1.84) 2 fewer per 1000 CRITICAL ⊕⊕⊕Ο (from 104 fewer to MODERATE 156 more)
1 2
One study identified 95% confidence interval indicated a benefit and a lack of benefit
WHO/HIV/2013.17
© World Health Organization 2013
Author(s): Amitabh Suthar Date: 2013-02-08 Question: Should phone calls vs standard of care be used for improving adherence to ART? Settings: Low- and middle-income countries Bibliography: Uzma Q, Emmanuel F, Ather U, Zaman S. Efficacy of Interventions for Improving Antiretroviral Therapy Adherence in HIV/AIDS Cases at PIMS, Islamabad. J Int Assoc Physicians AIDS Care (Chic). 2011 Nov-Dec;10(6):373-83
Quality assessment
No of patients
Effect Quality Importance
No of studies
Design
Risk of bias
Inconsistency
Indirectness Imprecision
Other considerations
Phone calls
Standard of care
Relative (95% CI)
Absolute
Treatment failure (follow-up 3 months; assessed with: Viral load > 50 copies/mL) 1 randomised no serious no serious trials risk of bias inconsistency1 no serious indirectness serious2 none 5/34 (14.7%) 6/34 (17.6%) RR 0.83 (0.28 to 2.47) 30 fewer per 1000 CRITICAL ⊕⊕⊕Ο (from 127 fewer to MODERATE 259 more)
Adherence < 95% (follow-up 3 months; assessed with: Self-reported) 1 randomised serious3 trials no serious inconsistency1 no serious indirectness serious2 none 4/34 (11.8%) 7/34 (20.6%) RR 0.57 (0.18 to 1.77) 89 fewer per 1000 (from 169 fewer to 159 more) ⊕⊕ΟΟ LOW CRITICAL
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One study identified 95% confidence interval indicated a benefit and a lack of benefit 3 Self-reported adherence susceptible to recall and social desirability bias
WHO/HIV/2013.17
© World Health Organization 2013
Author(s): Amitabh Suthar Date: 2013-02-08 Question: Should diaries vs standard of care be used for improving adherence to antiretroviral therapy? Settings: Low- and middle-income countries Bibliography: Wamalwa DC, Farquhar C, Obimbo EM, Selig S, Mbori-Ngacha DA, Richardson BA, Overbaugh J, Egondi T, Inwani I, John-Stewart G. Medication diaries do not improve outcomes with highly active antiretroviral therapy in Kenyan children: a randomized clinical trial. J Int AIDS Soc. 2009 Jun 824;12:8. doi: 10.1186/1758-2652-12-8.
Quality assessment
No of patients
Effect Quality Importance
No of studies
Design
Risk of bias Inconsistency Indirectness Imprecision
Other Standard of Diaries considerations care
Relative (95% CI)
Absolute
Treatment failure (follow-up 15 months; assessed with: Viral load > 100 copies/mL) 1 randomised trials no serious risk of bias no serious inconsistency1 serious2 serious3 none 7/14 (50%) 9/14 (64.3%) RR 0.78 (0.4 141 fewer per 1000 ⊕⊕ΟΟ to 1.49) (from 386 fewer to 315 LOW more) CRITICAL
Adherence < 95% (follow-up 15 months; assessed with: Self-reported) 1 randomised trials serious4 no serious inconsistency serious2 serious3 none 8/47 (17%) 5/43 (11.6%) RR 1.46 (0.52 to 4.13) 53 more per 1000 (from 56 fewer to 364 more) ⊕ΟΟΟ VERY LOW CRITICAL
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One study identified Population was children. Effectiveness of diaries may be different in adults. 3 95% confidence interval indicated a benefit and a lack of benefit 4 Self-reported adherence susceptible to recall and social desirability bias
WHO/HIV/2013.17
© World Health Organization 2013
Author(s): Amitabh Suthar Date: 2013-02-08 Question: Should calendars vs standard of care be used for improving adherence to antiretroviral therapy? Settings: Low- and middle-income countries Bibliography: Mugusi F, Mugusi S, Bakari M, Hejdemann B, Josiah R, Janabi M, Aboud S, Aris E, Swai H, Mhalu F, Biberfeld G, Pallangyo K, Sandstrom E. Enhancing adherence to antiretroviral therapy at the HIV clinic in resource constrained countries; the Tanzanian experience. Trop Med Int Health. 2009 Oct;14(10):1226-32.
Quality assessment
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Effect Quality Importance
No of studies
Design
Risk of bias
Inconsistency
Indirectness
Imprecision
Other Standard Calendars considerations of care
Relative (95% CI)
Absolute
Adherence < 95% (follow-up 12 months; assessed with: Self-reported) 1 randomised very no serious trials serious1 inconsistency2 no serious indirectness no serious imprecision none 39/2257 (1.7%)3 17/2395 (0.71%)3 RR 2.43 (1.38 to 4.29) 10 more per 1000 ⊕⊕ΟΟ CRITICAL (from 3 more to 23 LOW more)
1 2
No mention of sequence generation, allocation concealment, or blinding. Self-reported adherence susceptible to recall and social desirability bias One study identified 3 The numerator was the number of visits in which participants reported missing more than 3 doses in the past month while the denominator was the total number of visits